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12/30/2004 15:32 2099519?'', VILLAGE WEST MAF PAGE 01 <br />San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA, 95202 <br />Telephone (209) 4683420 Fax (209) 468-3433 <br />iiE Ci`,9 (-" s r <br />D E C 3 0 2004 <br />ENVIRONMENT HEALTH <br />.. FRVICES <br />Owner Statements of Designated Underground Stowage Tank (UST) Operator. <br />and Understanding ofand Compliance with UST Requirements <br />FacilityNanic �`-�_----�•-- -- -•-- ------ <br />Facility ID ft: <br />Facil' y Address: <br />Rcason for Submitting this Form (Check One) <br />iZ. ❑ Change of Designated Operator <br />Facility Phone #: Z4 ❑ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facilit <br />PRIMARY <br />Designated Operator's Name: DO w M Rclation to UST Facility (Check One) <br />Business Name (If differ eat f on, above): p C ❑ Owner ❑ Operator u Employcc <br />Designated Operator's Phone It: rf �� �. 7 �h C ❑ Service Technician )il Third -Party <br />International Codc Council Certification P: <br />AL,TERNATF, 1 (Qi,tianal <br />Designated Operator's Name: <br />Business Nanlc (lfdiffcreiaffronr above <br />Designated Operator's Phonc 0:- Qom_ <br />International Gods Council Certification t#; <br />AI; 111NATE Z (Ontiouali <br />Expiration Date: <br />Relation to UST Facility (Check One) <br />❑ Owncr ❑ Operator ❑ Empldyce <br />❑ Scrvice Technician A !Third -Party <br />(,del_ <br />1)csignatcd Operator's Nnmc ; y� - - --^ Rclation to UST Facility (Check <br />Busincss Mmic (lfrl,ffi,renjfi,oa,r uhorc). — ❑ Owncr ❑ Operator ❑ Employee <br />Designalcd Operator's 1,17011c N: 0 Scrvice Technician ❑ Third -Party <br />International Code Council Certification ft: Expiration Date: <br />INV A'k,: 'M, LOCAL RFC;ULA'T'ORY AGENCY MUST BZ NO'T'IFIED OF ANY CHANGES TO 'funs <br />INFORMATION WITHIN 30 DAYS OF THE CHANCE. <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspectiolas and annual facility employee training, in accordance with Califol-nia Code of <br />Regulations, title 23, section 2715(c) - (f). <br />Furthermore, I understand and ata in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage t211ks. <br />NAME OF TANK OWNER (Plense Print): nal 14 in� <br />SIGNATUR12, OIC 'TANK OWNER:'—_—w <br />DATE---� `- 24D —o �% . _. owNElt's P oNV f+: 2 0 C7 <br />November 2004 <br />